Counseling Intake Form
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3EEO COUNSELING – INTAKE INFORMATION
On
, you requested an appointment with an EEO Counselor.
Month, Day, Year
Informal Intake #:
/
/
Facility Abbreviation /
FY
/ Sequential ####
A. Counselee’s Information
Name (Last, First, Middle Initial)
Home Telephone No.
Fax No.
(
)
(
)
Your Mailing Address
(You must notify the Department of any changes of address while your complaint is pending, or your complaint may be dismissed)
Position Title
Series
Grade
Duty Hours
Time in Current Position
_____Years
_____Months
Employment Status in Relation to this Complaint (Check One)
Applicant
Probationary
Career/Career conditional
Retired ____________________________
Date of Retirement
Former Employee _____________________
Other ________________________________________________________________
Date left United States Mint
Specify
Name and Address of Facility Where You Work
Are you a Strategic Business Unit Employee?
Yes
No If the answer is yes, please check the following box to indicate the unit:
Chief Information’s Office
Chief Financial Office
Directors Staff
Manufacturing
Protection
Sales and Marketing
Your Work Telephone No.
Your Email Address
(
)
Your Supervisor’s Name
Supervisor’s Telephone No.
(
)
Supervisor’s Position Title
Series
Grade
Duty Hours
Supervisor’s Email Address
B. Discrimination Basis
Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, National Origin, Age (40+), Physical and/or Mental
Disability, or in
Retaliation (for prior EEO activity).
These categories are referred to on this form as basis.
Check and Particularize Each that Applies:
1. Race (Specify):
9. Age (Specify Date of Birth):
2. Color (Specify):
10. Physical Disability (Specify):
3. Religion (Specify):
11. Mental Disability (Specify):
4. Sex (Specify):
12. Reprisal (Dates of prior EEO Activity):
5. Genetic Information
6. Sexual Orientation
7. Parental Status
8. National Origin (Specify):
C. Matter Causing Complaint or Issue
Appointment
Pay
Time & Attendance
Assignment of Duties
Promotion (Provide the following information): Position Title:
Awards
Reassignment
Series & Grade:
Change to Lower Grade
Reinstatement
Announcement Number
Classification
Removal /Separation
Date you learned of non-selection:
Converted to F/T CC
Reprimand
Duty Hours
Resignation
Training
Evaluation-Appraisal Merit Pay
Retirement
Within Grade Increase
Evaluation-Appraisal Non-Merit Pay
Sex Based Harassment
Working Conditions
EEO Intake (11/03)
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